ANSWERS TO YOUR BILLING, CODING QUESTIONS: WINTER 2008

By Elizabeth W. Woodcock, MBA, FACMPE, CPC

Gaining a handle on unpredictable coding and compliance issues is vital to a healthy bottom line, not to mention both employee and patient satisfaction. Without the right tools and processes in place to manage through these constant changes, a practice’s cash flow, and standing with both patient and employees can quickly deteriorate. Here is a look at some of the common questions practices face, along with answers that will help keep you on the right side of payer policies and, ultimately, optimize reimbursement.

QUESTION: Is there anything that I can do if I disagree with a decision about a payment — the lack thereof — on one of my claims made by Medicare?

ANSWER: CMS provides five levels for physician practices to appeal a decision about a claim rejection.
The levels, listed in order, are:
• Redetermination by your Medicare carrier;
• Reconsideration by a Qualified Independent Contractor;
• Hearing by an Administrative Law Judge;
• Review by the Medicare Appeals Council within the Departmental Appeals Board; and
• Judicial review in U.S. District Court.
Contact your Medicare carrier, or download the CMS brochure on your rights to appeal at: http://www.cms.hhs.gov/MLNProducts/downloads/MedicareAppealsprocess.pdf. Depending on the amount of the claim in question, it’s worth your time. Experts report that a majority of payment rejections are overturned during the appeals process.

QUESTION: We use relative value units (RVU) to measure productivity, but we’ve run into some CPT® codes that have no units associated with them. What do we do?

ANSWER: Take the average charge per RVU from all known services, and then divide the charge for the code with no associated RVUs by the average. To illustrate, let’s say your average charge per RVU is $50 (for example, you charge $100 for a code worth two RVUs). If the charge for your unlisted code is $200, the estimated RVU is 4.0. This estimate holds if your charges are on a relatively consistent scale. Notably, you can also use cost accounting to develop an estimate of the units by using the same logic of computing the average of all other services – but instead of charges, use costs.

QUESTION: Does the HIPAA law forbid me to use a sign-in list?

ANSWER: No, as long as the list does not ask for what HIPAA defines as protected health information, which does not include listing one's name on a sign-in sheet or the time of arrival. Most practices still use sign-in lists to manage workflow. My recommendation is to lay the sign-in sheet aside, and endeavor to greet and register patients as they arrive. Use the sign-in list - or better yet, a pad of individual sign-in forms - only if a line forms.

QUESTION: Occasionally, I have an asthmatic patient who I monitor in the office. The patient is in the exam room for an hour and sometimes more. I know that I can bill for a level 4 or 5 office visit if I meet the criteria for one and document it, but is there anyway to bill for my time for this “extended” visit?

ANSWER: Evaluate the applicability of the prolonged care codes, which are 99354-99355 and 99356-99357, depending on the place of service, and the duration of time that you are actually face-to-face with the patient. (99358-99359 are also prolonged care codes, but for non-face-to-face services.) These codes are billed in addition to the office visit, and provide the opportunity to receive reimbursement for “prolonged services” such as those you describe. It is of note that the time spent by the physician must be more than 30 minutes (and documented), but the time does not have to be contiguous. Read the description of these codes carefully as they may provide the avenue for being reimbursed for these extended patient visits. Many payers will reimburse for prolonged care codes, although Medicare does not cover the non-face-to-face codes, 99358-9. For CMS’ description of the billing requirements for prolonged care codes, see http://cms.hhs.gov/mlnmattersarticles/downloads/mm5972.pdf.

Elizabeth Woodcock is the founder and principal of Woodcock & Associates, with 15 years experience in medical group operations and revenue cycle management. A speaker, trainer and author, Ms. Woodcock has led educational sessions for the Medical Group Management Association, the American College of Obstetricians & Gynecologists and the American Medical Association, and has consulted for clients as diverse as a solo orthopedic surgeon in rural Georgia to The Mayo Clinic. She is the author of Mastering Patient Flow to Increase Efficiency and Earnings, and co-author of The Physician Billing Process: Avoiding Potholes in the Road to Getting Paid and Operating Policies and Procedures Manual for Medical Practices.

>>BACK TO MAIN PAGE